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• SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY 1D # RECORD ID # INVOICE # G5_ FACILITY NAME �i 441- ri Q C �J "`��"` " BILLING PARAM Y / i��c� SITE ADDRESS (/ � - V RECEIVED CITY CA ZIP SAt��;, ;j1 ,6 PUBLIC I r,I (•rC OWNER/OPERATOR �� BILLING PARTY � 1Y DBA PHONE #1 ( ) ADDRESS PHONE #2 ( ) CITY STATE ZIP APN # Land Use Application # FIF BOS Dist Location Code CONTRACTOR and/or n �r / SERVICE REQUESTOR LC[�/jr�L�t�I ��✓� l /i�l�T�!)i C /�` BILLING PARTY ®Y / :NA DBA PHONE #1 t20 )-22 - AILING ADDRESS ' I FAX # (5-16 ) IIY7- �71 7 CITY � STATE ZIPS— 1 .J ILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific HS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN "JOAQUIN COUNTY Ordinance Codes and Standard , to and Federal laws. AN APPLICT' GNATURE Title Date AUTHORIZAT TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. f' Nature of Service Request: J Service Code 3 l'T Assigned to Employee # l J o Date /� / t Date Service Completed / / Further Action Required: Y / NPROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By SUPV / / ACCT /�Z/_ UNIT CLK _/ /